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❑ New Facility ] Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> COUNTRY CLUB MARKET& LIQUOR <br /> Site Address Cit State ZIP <br /> 1869-75 COUNTRY CLUB BLVD S�TOCKTON CA 95204 <br /> APN Supervisor District <br /> Type of Service 0 Application for 0 Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> if mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 2 Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Wafi Almhn <br /> Address City. State ZIP <br /> 1869-75 COUNTRY CLUB BLVD STOCKTON CA 95204 <br /> Phone Phone Email -T <br /> C �)g33- q3S3 (Si0)-k)a- <br /> 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law /� DATE: /� - P�• 1. <br /> APPLICANT'S SIGNATURE: /d ( �NT <br /> 0 PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT tVECJe1V,ED <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required SEP 03 <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above sit$0r hereby authoRYE the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EIt bEE�ETH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative- RQJy NTM <br /> Accepted By Assigned To Linked FA ID <br /> 3e C• �L dICti Q FA 0 lq 3� <br /> Date PE Fee Record Number <br /> Q Cash ❑Check# 8f Confirmationit r�/n2�3� Payment <br /> XS0{ li Received By <br /> Rev 07/10/2024 M 01 W 0WD <br />